ATS - soft tissue trauma

Emergency Medical Technician
26 – Soft Tissue Trauma
© 2014
Slide 2

© 2014
• Soft tissue trauma can take a variety
of forms
• You may encounter patients who have
only a minor scrape or superficial burn
• In other cases, you will encounter
patients with life-threatening
lacerations, deep puncture wounds or
severe burns
Slide 3

© 2014
• In order to provide the
best care for soft tissue
injuries, you must be
able to quickly assess
the type and severity of
the injury and provide
appropriate treatment
Slide 4

© 2014
1. Introduction
2. Closed Wounds
3. Open Wounds
4. Penetrating Injuries
5. Foreign Body in the Eye
6. Burn Injuries
7. Summary
Slide 5

© 2014
Slide 6

© 2014
Slide 7
• Soft tissue wounds can be:
– Closed
– Open

© 2014
• A closed wound is an
injury with no opening to
the outside of the body but
may include significant
deep tissue or body cavity
injuries
• Closed wounds typically
result from blunt force
trauma
• Injuries may not always
be evident on initial
inspection, so assess
based on the mechanism
of injury
Slide 8

© 2014
• Examples of closed
injuries include:
– Contusions
– Hematomas
– Some crush injuries
– Internal lacerations or
punctures caused by
fractured bones
– Ruptures of internal
organs
• Closed injuries can also
occur in combination
with other open injuries
Slide 9

© 2014
• A hematoma is similar to a
contusion:
– Involves larger blood
vessels
– Greater tissue damage
– Creates greater
internal blood loss
• Hematomas often occur in
orthopedic injuries at:
– Fracture sites
– Intramuscularly
abdomen
– Scalp or skull
Slide 10

© 2014
• Emergency care for
closed wounds requires:
– Assessment and
management of the
ABCs
– Splinting of extremities
if required
– Care for shock if
internal bleeding is
supspected
Slide 11

© 2014
Slide 12
• Administer oxygen as
needed or according to
protocols
• Be alert for vomiting
and risk of aspiration
• Monitor the ABCs and
vital signs every 5
minutes while you
transport

© 2014
Slide 13

© 2014
• An open wound is an
injury in which the skin
is broken or penetrated
• There may or may not
be visible underlying
tissues or bleeding
• A break in the skin can
come from an outside
mechanism, such as a
knife, or from the
inside, such as a broken
bone
Slide 14

© 2014
Slide 15
• The six general kinds of
open injuries are:
– Abrasions
– Lacerations
– Avulsions
– Some crush injuries
– Amputations
– Penetrations or
punctures
• These injuries can occur
in combination with
each other and with
closed injuries

© 2014
Slide 16
• The two most common
open wounds you will
encounter are:
– Abrasions
– Lacerations
• The severity of the
injury will depend on
the:
– Mechanism
– Location of the injury

© 2014
• Abrasions can be:
– Superficial wounds
– Moderate to severe injuries
– Involving many layers of skin
including deeper connective tissues
and fat
Slide 17

© 2014
• Superficial abrasions
have:
– Minimal bleeding
– Extremely painful
because of the
exposure of nerve
endings
Slide 18

© 2014
• Moderate and severe
abrasions involve more
layers of skin and are
often accompanied by:
– Moderate and
occasionally severe
bleeding
Slide 19

© 2014
• A full-thickness
abrasion involving all
layers of the skin:
– May not bleed
significantly, or;
– Be very painful due to
the abradement of
nerve endings
• Superficial and
moderate abrasions
tend to be the most
painful
Slide 20

© 2014
• Infection is always a
concern with soft tissue
injuries but especially
abrasion injuries due to
ground-in dirt, gravel or
other contaminants
Slide 21

© 2014
Slide 22
• Lacerations involve a cut
or break in the skin that
can be:
– A smooth cut or incision,
– A jagged cut
• These injuries can be
superficial, or very deep
• Injury can result in serious
blood loss depending on
the location and whether
major blood vessels have
been cut

© 2014
Slide 23
• An avulsion is an injury
in which a flap of tissue
or body part, such as a
fingertip, has either
been torn loose or
completely detached
from the body
• Avulsions commonly
result from accidents
with machinery or
vehicles

© 2014
• Extremities are frequently involved
• The site of an avulsion can bleed
significantly, though a small amount
of bleeding does not indicate that the
injury is minor
• Some vessels can tamponade, or
become compressed, by retracting
into soft tissue, limiting bleeding
Slide 24

© 2014
• These injuries can be
grotesque and
frightening
– Provide reassurance
throughout the call
• If the skin or another
body part is torn from
the area:
– Control bleeding
– Dress the wound using
a bulky pressure
dressing
Slide 25

© 2014
• The severity of an
avulsion is determined
by the degree of
circulation and
perfusion of the tissues
distal to the injury
• If the tissue is cut off
from its blood source, it
usually dies unless
rapid surgical
intervention is able to
preserve it
Slide 26

© 2014
• Crush injuries can be an
open or closed soft
tissue injury
• These injuries can
result when a part of
the body is compressed
or struck by a heavy
object
Slide 27

© 2014
• An open crush injury often involves an
extremity:
– Blood vessels
– Nerves
– Muscle
– Bone
• These can all be damaged, and severe
swelling can compromise distal perfusion
Slide 28

© 2014
Slide 29
• The severity of injury
will depend on the
force, mechanism and
pressure of the crushing
object involved
• A closed crush injury
can rupture solid and
hollow organs, causing
them to leak blood and
their contents into body
cavities

© 2014
Slide 30
• Crush injuries,
regardless of being
open or closed can:
– Bleed profusely
– Rapidly lead to shock
• Risk is particularly
likely when the object
that has caused the
injury is moved away
from crushed vessels,
which then begin to
bleed profusely

© 2014
• To manage an open
wound:
– Carefully expose the
area
– Cut away clothing if
necessary
• Leave the wound intact
rather than trying to
open it to determine its
depth
• Control serious bleeding
using direct pressure
Slide 31

© 2014
• If bleeding continues:
– Keep the existing
dressing in place
– Apply any additional
dressing on top of it
• Once the bleeding has
stopped:
– Cover the area with
sterile dressing
– Bandage it in place
Slide 32

© 2014
• Check for a distal pulse
if the wound is on an
extremity
• Evaluate the mechanism
of injury
– Have a high index of
suspicion for internal
injuries if the force
involved was
significant, or it
involved a critical area
of the body
Slide 33

© 2014
Slide 34
• Anticipate and treat the
patient for shock
• Don’t wait for signs or
symptoms to appear,
particularly if the injury
is severe

© 2014
• Provide oxygen at 15
LPM or per protocols
• Provide reassurance
– Keeps patient calm
– Helps control vital
signs
• Transport to the
appropriate receiving
hospital
Slide 35

© 2014
Slide 36
• If the patient has
suffered the traumatic
amputation of a limb or
part of a limb, take
particular care with the
severed part
• Locate the severed body
part and wrap it in a
moist, sterile dressing

© 2014
• Label a re-sealable plastic
bag including the:
– Patient’s name
– Date
– Time
• Also include the:
– Name and/or
identification number
of the responder who
personally handled the
body part
• Place the body part inside
Slide 37

© 2014
• Seal the bag tightly to
prevent the part from
getting too wet or
further contaminated
• Place the bag on cold
packs or in a container
with ice and water:
– Taking care not to
place the part in direct
contact with the ice
•
Slide 38

© 2014
• Be sure the part gets
transported to the
hospital with the
patient
• The person who has
identified and handled
the body part must be
available to the hospital
staff to verify the
identity of the patient
and the body part if
necessary
Slide 39

© 2014
Slide 40

© 2014
• A penetrating injury is
caused when an object
passes through the skin
or other tissue
• The damage caused and
the amount of bleeding
is dependent on the
amount of force and
velocity of the object
when it enters the body
Slide 41

© 2014
• Penetration injuries are
commonly caused by:
– Sharp objects
– Animal bites
– Knives
– Bullets
Slide 42

© 2014
• When managing a
penetrating injury that
is caused by a medium-
or high-velocity
mechanism like a bullet,
expect a significant
amount of internal
injury and internal
bleeding due to the
concussive effect from
the shock wave of the
penetrating object
Slide 43

© 2014
• Check for an exit wound
on the opposite side of
the patient from the site
of entrance
– If present, it can be
larger and more
serious than an
entrance wound
• Treat for shock and
prepare patient for
transport
Slide 44

© 2014
• Expose the wound,
cutting the clothing if
needed
– If a crime is involved,
cut around—not
through—the holes to
preserve evidence
Slide 45

© 2014
• Care for the wound as
you would any other
injury
– Control bleeding
– Applying dressing and
bandaging
Slide 46

© 2014
• An impaled object
creates a penetrating
wound and remains
embedded in the
injured tissue
• Leave penetrating
objects in place
• Objects may help to
seal off damaged blood
vessels
– This can help to
prevent serious blood
loss or further injury
Slide 47

© 2014
Slide 48
• To manage an
impalement injury:
– Manually secure the
object to keep it stable,
especially if it is long
– Expose the area around
the wound, cutting
surrounding clothing if
necessary
 Take care not to
disturb the object

© 2014
• If the bleeding is
profuse, use direct
downward pressure
without touching the
object or putting
pressure on the tissues
along its edges
• Gauze dressings can be
used to distribute the
pressure to a wider
area
Slide 49

© 2014
• Stabilize the object by
surrounding it on all
sides with bulky
dressing
– Maintain pressure on
the wound margins to
control the bleeding
• The dressing should be
placed:
– On opposite sides of
the object
– Along the long axis of
the body
– Held in place by hand
Slide 50

© 2014
• Another layer of
dressing should be
placed perpendicular to
and on top of the first
layer
• Continue to stack
dressing until as much
of the object is
stabilized as possible
• Bandage the dressings
in place
Slide 51

© 2014
Slide 52
• Provide care for shock
• Administer oxygen
according to your
protocols
• Keep the patient still
and prepare for
transport
• The impaled object
should be observed at
all times to prevent
movement or
displacement

© 2014
• If the object is impaled
in the cheek:
– Leave it in place unless
there is uncontrolled
bleeding, which can
restrict your ability to
manage the airway
Slide 53

© 2014
• Protect the airway
– The object can obstruct
the airway
– Bleeding in the mouth
and throat can
interfere with
breathing
– Bleeding can cause
nausea and vomiting
Slide 54

© 2014
• If there is a risk of neck
or spine injury and the
patient is alert and
cooperative, pack
dressing material
between the inner
cheek and teeth instead
of turning the patient’s
head
Slide 55

© 2014
• Allow a portion of the
dressing to remain
outside the mouth to
prevent an airway
obstruction and to be
visible to other care
givers
• Make sure it does not
block the airway
Slide 56

© 2014
• Provide oxygen, using a
nasal cannula if
constant suction is
required
• Continue to monitor and
reassess while en route
Slide 57

© 2014
Slide 58

© 2014
• The eyes are highly
susceptible to injury
from foreign objects
• While most intrusions
by foreign bodies cause
only minor irritation,
others can cause
permanent injury
• Common foreign matter
in the eye can include
dirt, dust or chemicals
Slide 59

© 2014
• The signs and
symptoms of a foreign
body in the eye include:
– Pain
– Tearing
– Redness
– Blurry vision
Slide 60

© 2014
• If the patient’s tears
have not washed the
object away and
medical direction or
local protocol permits,
try to flush it out
Slide 61

© 2014
• Usually, the eye will
flush out small foreign
objects through blinking
and tearing
• Lay the patient flat with
the head turned toward
the side affected in
order to protect the
unaffected eye
Slide 62

© 2014
• While holding the lid
open with your gloved
hand, apply pressure to
the bones around the
eye without pressing on
the eye itself
• Continuously flush with
water or saline until:
– The object is removed
– Or until the amount of
fluid your protocol
allows has been
exhausted
Slide 63

© 2014
• Pour at the corner of the
eye closest to the nose,
directing the patient to
look up, down and from
side to side
• Direct the patient to blink
several times during
flushing
• The patient may feel,
taste, or smell the fluid
running down the back of
the throat
– This is normal since the
tears drain into the nose
Slide 64

© 2014
• Cover both eyes with
moistened pads to limit
eye movement
• Resume flushing if the
patient complains about
renewed burning or
irritation
• Prepare patient for
transport
Slide 65

© 2014
Slide 66

© 2014
• Burns can damage or
destroy the structures
and function of the skin
• They can also cause
damage to other body
systems
Slide 67

© 2014
• The severity of any burn
is determined by
several factors:
– The cause
– The depth
– The extent
– The body part involved
– The presence of
respiratory
involvement
Slide 68

© 2014
• Burns are commonly
classified by their
causes
• The most common
causes of the burns you
are likely to encounter
are:
– Thermal
– Chemical
– Electrical
Slide 69

© 2014
• A thermal burn, the
most common type of
burn, and are caused
by:
– Fire
– Scalding water
– Hot objects
Slide 70

© 2014
• A chemical burn can be
caused by contact with
caustic materials:
– Household or industrial
chemicals, including
lye, cleansers or acids
Slide 71

© 2014
• An electrical burn can
be caused by contact
with electrical current
from:
– Power lines
– Faulty circuits
– Lightning
• The amount of electric
current and the voltage
determine the severity
of the burn
Slide 72

© 2014
Slide 73
• Burns are also classified
by depth of the injury,
or by the layers of skin
involved
• Symptoms will vary

© 2014
• The skin has three
layers:
– Epidermis
– Dermis
– Subcutaneous layer
Slide 74

© 2014
• The epidermis is the
body’s major barrier
against infection:
– The outermost layer
– Comprised of about 4
layers of cells
Slide 75

© 2014
• The dermis is made of
dense connective tissue
• It contains a vast
network of blood
vessels, nerves and
sweat glands
Slide 76

© 2014
• The subcutaneous layer
is fatty tissue that helps
in shock absorption and
with insulation
Slide 77

© 2014
• Superficial burns:
– Involve only the
epidermis
– Tend to heal on their
own
Slide 78

© 2014
• The signs and
symptoms of superficial
burns are:
– Pain
– Redness of the skin
– Swelling
Slide 79

© 2014
• Partial-thickness burns
involve:
– The epidermis
– The dermis
• The signs and
symptoms of partial-
thickness burns are:
– Deep, intense pain
– Redness of the skin
– Blisters or a moist
appearance
Slide 80

© 2014
• Full-thickness burns
extend through all three
layers of the skin and
can damage additional
underlying tissue and
bone
Slide 81

© 2014
• The signs and
symptoms of full-
thickness burns are:
– A white, yellow, tan,
brown or charred
appearance
– Leathery feel
– Lack of pain in the
deep burn areas
Slide 82

© 2014
• Full-thickness burns
result in nerve damage
that deadens pain
receptors;
• However, these burns
are often accompanied
by painful partial-
thickness burns in the
surrounding areas
Slide 83

© 2014
• The extent of the burn
requires an estimation
of how much of the
body surface is burned
to help determine
whether the patient is
likely to develop shock
or other complications
Slide 84

© 2014
• The rule of nines is used
to:
– Approximate the
amount of skin surface
burned by dividing the
body into sections that
comprise
approximately nine
percent of the total
surface area
Slide 85

© 2014
• For an adult, each of these
areas is given a valuation
of 9%:
– Entire head
– One entire arm
– Front of one entire leg
– Back of one entire leg
– Chest
– Shoulders and upper
back
– Abdominal area
– Lower back and
buttocks
Slide 86

© 2014
• The remaining one
percent of surface area
comprises the genital
area
• The percentages differ
for children and infants,
with a greater
percentage attributable
to the head
Slide 87

© 2014
• When assessing the
severity of the injury,
also consider the part of
the body burned
• Especially serious are
burns to the:
– Hands
– Feet
– Face
– Groin
– Armpits
– Neck
Slide 88

© 2014
• Considerations when
determining severity
and priority for
transportation include:
– The patient’s pre-
existing medical
conditions
– Other injuries
– Age
Slide 90

© 2014
• The airway can suffer
injury caused by:
– The inhalation of
smoke
– Superheated air
– Toxic fumes
• This can result in
airway swelling or other
breathing problems
– It may be evident by
soot or burns to the
back of the mouth,
throat and nasal
cavities
Slide 92

© 2014
• Administer oxygen at
15 lpm by
nonrebreather mask
• Quickly conduct your
primary assessment
• Classify the severity of
the burn, and BSA
percentage
• Determine if priority
transport is needed
Slide 93

© 2014
• Remove any
constrictive clothing or
jewelry, especially rings
• If clothing is adhered to
the wound, leave it in
place
• Cool water or saline can
be applied to help
reduce pain, swelling
and the depth of injury
Slide 94

© 2014
• Throughout your care,
continuously monitor
the airway for swelling
or breathing difficulty
– The first sign may be
hoarseness or
wheezing
Slide 95

© 2014
• Cover the burned area
with a dry, sterile
dressing to prevent
further contamination
– Leave blisters intact
– No ointments, lotion or
antiseptics should be
applied
 If these have been
previously applied by
someone, leave them
in place for burn
specialists to remove
Slide 96

© 2014
Slide 97
• If ice or cold packs are
used, wrap them first so
they are not directly on
the injury
• Burns can disrupt the
body’s ability to
regulate temperature
• To prevent
hypothermia, cover and
keep the patient warm

© 2014
• When treating burns to
the hands or feet,
separate the fingers or
toes with sterile gauze
prior to bandaging
Slide 98

© 2014
• Burns to the eyes or
eyelids should be
treated by placing moist
dressings loosely over
both closed eyes, even
if only one eye is
injured
– This helps prevent
movement of the
injured eye
Slide 99

© 2014
• Transport burn patients to the
appropriate facility:
– Based on the severity of injury
– Transport protocols
Slide 100

© 2014
• When burns are caused
by chemicals, be
mindful of scene safety
at all times
• Always use personal
protective equipment
• Notify dispatch of
hazardous materials
incidents according to
your protocols
Slide 101

© 2014
Slide 103
• Flush the area with
copious amounts of
water for a minimum of
20 minutes
– Direct the contaminant
away from the patient
• Apply a dry sterile
dressing

© 2014
Slide 104
• If the eyes are involved,
flush the entire area
continuously with water
• If only one eye is
affected, keep the flow
away from the
unaffected eye

© 2014
Slide 105
• Use moistened pads to
cover both eyes
• If the patient complains
about renewed burning
or irritation, resuming
flushing and then
reapply the pads

© 2014
• You should transport burn patients to
the appropriate facility, based on the
severity of injury or your transport
protocols
Slide 106

© 2014
Slide 107
• If the injuries were
caused by electrical
burns:
– Confirm that the
source has been
disconnected before
entering the scene
• Provide manual
stabilization of the head
and neck if indicated

© 2014
• The internal injuries
caused by electrical
current can cause
complications in
respiratory, cardiac and
nervous system
functioning
– These injuries can be
much more serious
than the actual burns
– Expect and prepare for
the possibility of
cardiac arrest
Slide 108

© 2014
Slide 109
• Examine for 2 burn sites
• There may be an
entrance wound and an
exit wound
– The entrance wound is
often located on the
hand and is typically
smaller
– The exit wound is often
located on the foot and
is typically larger and
more obvious

© 2014
• Apply dry sterile dressings
to the burn sites
• Provide care for shock
• Prepare for transport
• Monitor vital signs observe
for:
– Improvement
– Deterioration of the
patient’s condition
• If the patient cannot be
stabilized, arrange for ALS
intercept
Slide 111

© 2014
• Soft tissue traumas are very common
injuries
• You can expect to encounter a wide
range of soft tissue injuries, even on
the same call
• Your understanding of how to quickly
and carefully manage soft tissue
trauma can help to minimize the long-
term and often devastating effects of
these injuries
Slide 113

ATS - soft tissue trauma

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